Monthly publications : February 2010 | WebSurg, the online university of IRCAD

Thoracoscopic left upper lobectomy for stage I lung carcinoma

This is the case of a 59-old female smoker who had an undetermined 2cm nodule in the left upper lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control and revealed a primary adenocarcinoma (stage I lung carcinoma). 18-FDG scintigraphy showed a significant and isolated fixation. A thoracoscopic left upper lobectomy is presented.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1

D Gossot

Surgical intervention

Thoracoscopic left upper lobectomy for stage I lung carcinoma

This is the case of a 59-old female smoker who had an undetermined 2cm nodule in the left upper lobe. Bronchoscopy was normal. A biopsy was performed under CT-scan control and revealed a primary adenocarcinoma (stage I lung carcinoma). 18-FDG scintigraphy showed a significant and isolated fixation. A thoracoscopic left upper lobectomy is presented.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1

Transvaginal hybrid NOTES cholecystectomy using an internal retractor

Under general anesthesia with the patient supine in lithotomy position, a pelvic exam is performed. A first 5mm umbilical trocar is placed and an exploratory laparoscopy is performed to ascertain the feasibility of a NOTES cholecystectomy. The patient is then tilted in steep Trendelenburg. The posterior vaginal vault is carefully examined before gaining access to the peritoneal cavity. A linear cold blade scalpel incision is made in the cul-de-sac, well posterior in the fold between the uterosacral ligaments, 1cm below the uterine os.

B Dallemagne, S Perretta, J Marescaux

Surgical intervention

Transvaginal hybrid NOTES cholecystectomy using an internal retractor

Under general anesthesia with the patient supine in lithotomy position, a pelvic exam is performed. A first 5mm umbilical trocar is placed and an exploratory laparoscopy is performed to ascertain the feasibility of a NOTES cholecystectomy. The patient is then tilted in steep Trendelenburg. The posterior vaginal vault is carefully examined before gaining access to the peritoneal cavity. A linear cold blade scalpel incision is made in the cul-de-sac, well posterior in the fold between the uterosacral ligaments, 1cm below the uterine os.

Emergency endoscopic removal of intragastric balloon for hematemesis and melena

The BioEnterics® Intragastric Balloon (BIB®) System has been developed as a temporary aid to achieve weight loss in obese people that are 40% or more above their optimal weight, in patients who have had unsatisfactory results in their treatment of morbid obesity despite being cared for by a multidisciplinary team, and in superobese patients for whom surgery is often associated with high risks. The BIB® reduces the volume of the stomach and leads to a premature feeling of satiety. The placement and removal of the BIB® is an interventional endoscopic procedure and the balloon is designed to float freely inside the stomach; its size can be changed during the placement.
The technique has absolute contraindications such as voluminous hiatus hernia, abnormalities of the pharynx and esophagus, esophageal varicose veins, use of anti-inflammatory or anti-coagulant drugs, pregnancy and psychiatric disorders. Relative contraindications are esophagitis, ulceration and acute lesions of the gastric mucous membrane. The complications of the BIB® are related to the endoscopic method itself, to sedation and perforation, to its prolonged contact with the mucous membrane and its migration, which may result in esophageal or intestinal obstruction (1). The patients must be clinically supervised during the BIB® placement. Complications and symptoms, such as esophageal injury and vomiting due to BIB® slippage must be described to the patient, along with the possibility that the BIB® may require early endoscopic removal. Since the BIB® works as an artificial bezoar, the patients usually show a maximal reduction in ingestion around the fourth week, and return to normal after 12 weeks.

(1) Mathus-Vliegen EMH. Efficacy of bioenterics intragastric balloon treatment in a prospective 2 years follow-up study. Presented at the Eighth European Congress on Obesity; 1997 Aug. Dublin, Ireland: European Congress on Obesity, 1997.

Gf Donatelli, C Callari, S Perretta, B Dallemagne

Surgical intervention

Emergency endoscopic removal of intragastric balloon for hematemesis and melena

The BioEnterics® Intragastric Balloon (BIB®) System has been developed as a temporary aid to achieve weight loss in obese people that are 40% or more above their optimal weight, in patients who have had unsatisfactory results in their treatment of morbid obesity despite being cared for by a multidisciplinary team, and in superobese patients for whom surgery is often associated with high risks. The BIB® reduces the volume of the stomach and leads to a premature feeling of satiety. The placement and removal of the BIB® is an interventional endoscopic procedure and the balloon is designed to float freely inside the stomach; its size can be changed during the placement.
The technique has absolute contraindications such as voluminous hiatus hernia, abnormalities of the pharynx and esophagus, esophageal varicose veins, use of anti-inflammatory or anti-coagulant drugs, pregnancy and psychiatric disorders. Relative contraindications are esophagitis, ulceration and acute lesions of the gastric mucous membrane. The complications of the BIB® are related to the endoscopic method itself, to sedation and perforation, to its prolonged contact with the mucous membrane and its migration, which may result in esophageal or intestinal obstruction (1). The patients must be clinically supervised during the BIB® placement. Complications and symptoms, such as esophageal injury and vomiting due to BIB® slippage must be described to the patient, along with the possibility that the BIB® may require early endoscopic removal. Since the BIB® works as an artificial bezoar, the patients usually show a maximal reduction in ingestion around the fourth week, and return to normal after 12 weeks.

(1) Mathus-Vliegen EMH. Efficacy of bioenterics intragastric balloon treatment in a prospective 2 years follow-up study. Presented at the Eighth European Congress on Obesity; 1997 Aug. Dublin, Ireland: European Congress on Obesity, 1997.

Laparoscopic TEP repair for recurrent inguinal hernia after anterior plug hernioplasty

In this video, we show the case of a patient who had undergone an anterior approach Plug treatment for an inguinal hernia. One year later, this patient presents with an obvious and painful recurrence that is well identified following a Valsalva's maneuver. We decide to perform a totally extraperitoneal laparoscopic approach.

B Dallemagne, F Costantino, J Marescaux

Surgical intervention

Laparoscopic TEP repair for recurrent inguinal hernia after anterior plug hernioplasty

In this video, we show the case of a patient who had undergone an anterior approach Plug treatment for an inguinal hernia. One year later, this patient presents with an obvious and painful recurrence that is well identified following a Valsalva's maneuver. We decide to perform a totally extraperitoneal laparoscopic approach.

New curved and reusable instruments for single access laparoscopic cholecystectomy

This video demonstrates a laparoscopic single incision cholecystectomy using new curved and reusable instruments: a grasper with double curves and a hook with a single curve. A reusable 10mm trocar is inserted.

G Dapri, L Casali, J Himpens, GB Cadière

Surgical intervention

New curved and reusable instruments for single access laparoscopic cholecystectomy

This video demonstrates a laparoscopic single incision cholecystectomy using new curved and reusable instruments: a grasper with double curves and a hook with a single curve. A reusable 10mm trocar is inserted.

One glove single port cholecystectomy: some tips and tricks

Single incision laparoscopic surgery (SILS) was developed with the aim of reducing the invasiveness of traditional laparoscopy. The aim of this video is to show tips that are useful when performing a cholecystectomy with a single umbilical trocar while respecting the rules of biliary surgery.

J Leroy, F Costantino, J Marescaux

Surgical intervention

One glove single port cholecystectomy: some tips and tricks

Single incision laparoscopic surgery (SILS) was developed with the aim of reducing the invasiveness of traditional laparoscopy. The aim of this video is to show tips that are useful when performing a cholecystectomy with a single umbilical trocar while respecting the rules of biliary surgery.

Multi-recurrent right inguinal hernia: advantages of the laparoscopic TAPP approach

Laparoscopic TAPP hernia repair is technically difficult, but in the hands of a well-trained surgeon, it is safe and effective in recurrent hernia too. The objective of this video is to demonstrate how a multi-recurrent hernia in the right inguinal region can be treated laparoscopically using a TAPP approach. The patient had been operated upon using an anterior repair first. For the first recurrence, a laparoscopic posterior approach with placement of a posterior bilateral prosthesis via a TAPP approach was performed. The repair of the second recurrence was achieved with placement of a 4D-DOME prosthesis.

J Leroy, C Callari, J Marescaux

Surgical intervention

Multi-recurrent right inguinal hernia: advantages of the laparoscopic TAPP approach

Laparoscopic TAPP hernia repair is technically difficult, but in the hands of a well-trained surgeon, it is safe and effective in recurrent hernia too. The objective of this video is to demonstrate how a multi-recurrent hernia in the right inguinal region can be treated laparoscopically using a TAPP approach. The patient had been operated upon using an anterior repair first. For the first recurrence, a laparoscopic posterior approach with placement of a posterior bilateral prosthesis via a TAPP approach was performed. The repair of the second recurrence was achieved with placement of a 4D-DOME prosthesis.

The mobilization of the lateral wall of the parasellar region

The elevation of the lateral wall of the cavernous sinus (temporal fossa dura) is one of the key steps of several extradural approaches to the skull base and is necessary to separate the intradural and extradural part of cavernous sinus tumors, most especially meningiomas.

E Gay

The mobilization of the lateral wall of the parasellar region

The elevation of the lateral wall of the cavernous sinus (temporal fossa dura) is one of the key steps of several extradural approaches to the skull base and is necessary to separate the intradural and extradural part of cavernous sinus tumors, most especially meningiomas.

Anterolateral approach to the cavernous sinus: a neuroanatomist’s perspective of surgical nuances

In this key lecture, Prof. Jeffrey Thomas Keller presents some anatomical features essential to perform anterolateral approaches to the skull base. Those nuances are mandatory to maximize the surgical approach and reduce the morbidity.

Anterolateral approach to the cavernous sinus: a neuroanatomist’s perspective of surgical nuances

In this key lecture, Prof. Jeffrey Thomas Keller presents some anatomical features essential to perform anterolateral approaches to the skull base. Those nuances are mandatory to maximize the surgical approach and reduce the morbidity.

The Fronto-Temporal-Orbito-Zygomatic (FTOZ) approach

The Fronto-Temporal-Orbito-Zygomatic (FTOZ) approach is one of the standard skull base approaches. It provides a great exposure of the caverno-orbital junction and central skull base.
It lowers the line of sight for access to the suprasellar region.
The one piece approach is based on the MacCarty keyhole and understanding the anatomy of the Inferior Orbital Fissure (IOF) is essential.

The Fronto-Temporal-Orbito-Zygomatic (FTOZ) approach

The Fronto-Temporal-Orbito-Zygomatic (FTOZ) approach is one of the standard skull base approaches. It provides a great exposure of the caverno-orbital junction and central skull base.
It lowers the line of sight for access to the suprasellar region.
The one piece approach is based on the MacCarty keyhole and understanding the anatomy of the Inferior Orbital Fissure (IOF) is essential.

Anterior clinoidectomy

The anterior clinoidectomy technique, especially when performed extradurally, requires a perfect 3D visualization of the anatomy of the Anterior Clinoid Process (APC) and its relationship with major surrounding structures (Internal Carotid Artery, optic nerve, and oculomotor nerve).

Anterior clinoidectomy

The anterior clinoidectomy technique, especially when performed extradurally, requires a perfect 3D visualization of the anatomy of the Anterior Clinoid Process (APC) and its relationship with major surrounding structures (Internal Carotid Artery, optic nerve, and oculomotor nerve).

Mucosal skinning of the bladder for endometriosis

In this video, we show a technique to excise a non-infiltrating endometriotic nodule of the bladder wall. After MRI study and cystoscopy, the decision to do a mucosal skinning is undertaken. Filling of the bladder, use of adequate energy and traction are the main features to perform mucosal skinning. The bladder serosa is then sutured.

A Wattiez, J Nassif, B Gabriel, S Barata, J Marescaux

Surgical intervention

Mucosal skinning of the bladder for endometriosis

In this video, we show a technique to excise a non-infiltrating endometriotic nodule of the bladder wall. After MRI study and cystoscopy, the decision to do a mucosal skinning is undertaken. Filling of the bladder, use of adequate energy and traction are the main features to perform mucosal skinning. The bladder serosa is then sutured.

Laparoscopic ureteral anastomosis in a patient with hydronephrosis due to a severe endometriosis

Ureteral endometriosis is unfrequent and it is defined by the presence of endometrial glands in the ureteric or pre-ureteric tissue. The prevalence reported is less than 1% and usually confined to the lower one-third of the left ureter. This pathology generates a ureteral stenosis, with an extrinsic compression of the ureteral wall by the inflammatory response and fibrosis, or an intrinsic stenosis with the invasion of the uro-epithelium and submucosal layer of the ureteral wall. We present a short video describing the technique of the laparoscopic segmental ureteral resection followed by the re-anastomosis.

I Miranda-Mendoza, J Nassif, E Kovoor, A Wattiez

Surgical intervention

Laparoscopic ureteral anastomosis in a patient with hydronephrosis due to a severe endometriosis

Ureteral endometriosis is unfrequent and it is defined by the presence of endometrial glands in the ureteric or pre-ureteric tissue. The prevalence reported is less than 1% and usually confined to the lower one-third of the left ureter. This pathology generates a ureteral stenosis, with an extrinsic compression of the ureteral wall by the inflammatory response and fibrosis, or an intrinsic stenosis with the invasion of the uro-epithelium and submucosal layer of the ureteral wall. We present a short video describing the technique of the laparoscopic segmental ureteral resection followed by the re-anastomosis.

Right laparoscopic partial nephrectomy for a mesorenal tumor of the right kidney

The video "Right laparoscopic partial nephrectomy for a mesorenal tumor of the right kidney" authored by T Piechaud, OA D'Orazio, and C Fraga-Pereira is analysed by Prof. Roland van Velthoven, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

R Van Velthoven, T Piéchaud, OA D'Orazio, C Fraga

Surgical intervention

Right laparoscopic partial nephrectomy for a mesorenal tumor of the right kidney

The video "Right laparoscopic partial nephrectomy for a mesorenal tumor of the right kidney" authored by T Piechaud, OA D'Orazio, and C Fraga-Pereira is analysed by Prof. Roland van Velthoven, sharing in this way his own personal experience and highlighting the different surgical approaches available with tips and tricks.

SILS total colectomy with end ileostomy

Single incision laparoscopic surgery (SILS) is emerging as a method to improve morbidity and cosmetic benefits of laparoscopic surgery. This is the case of a 27-year-old woman presenting with ulcerative colitis. Because of her young age and slim body habitus, a total colectomy using a single port laparoscopic technique is performed with the SILS system manufactured by Covidien.

R Cahill, I Lindsey, O Jones, R Guy, N Mortensen, C Cunningham

Surgical intervention

SILS total colectomy with end ileostomy

Single incision laparoscopic surgery (SILS) is emerging as a method to improve morbidity and cosmetic benefits of laparoscopic surgery. This is the case of a 27-year-old woman presenting with ulcerative colitis. Because of her young age and slim body habitus, a total colectomy using a single port laparoscopic technique is performed with the SILS system manufactured by Covidien.

What is your opinion and rating of this IRCAD course in neurosurgery?

JT Keller, ML Pensak, S Froelich, J Morcos, C Debry, HR Van Loveren, B George, PV Theodosopoulos

What has been your highlight of the course so far?

HR Van Loveren, ML Pensak, S Froelich, J Morcos, B George, JT Keller

What aspect of the course did you find most interesting?

B George, JT Keller, HR Van Loveren, J Morcos, S Froelich

How do you feel this course will benefit the participants?

HR Van Loveren, JT Keller, C Debry, S Froelich

Get into the ambiance of the first neurosurgery course at IRCAD-EITS, January 20-22, 2010

Surgery in and around the cavernous sinus: state of the art

In this key lecture, Professor Harry van Loveren, whose experience in cavernous sinus meningioma surgery is extensive, presents the evolution of therapeutic strategies as well as the current management options for those lesions.

Surgery in and around the cavernous sinus: state of the art

In this key lecture, Professor Harry van Loveren, whose experience in cavernous sinus meningioma surgery is extensive, presents the evolution of therapeutic strategies as well as the current management options for those lesions.

12cm right pheochromocytoma: not a contraindication to a laparoscopic approach

Laparoscopic adrenalectomy is now accepted as the procedure of choice for the resection of benign adrenocortical tumors. This video shows the laparoscopic approach for a 12cm right pheochromocytoma, demonstrating that the size is not a contraindication for laparoscopy.

D Mutter, L Soler, J Marescaux

Surgical intervention

12cm right pheochromocytoma: not a contraindication to a laparoscopic approach

Laparoscopic adrenalectomy is now accepted as the procedure of choice for the resection of benign adrenocortical tumors. This video shows the laparoscopic approach for a 12cm right pheochromocytoma, demonstrating that the size is not a contraindication for laparoscopy.

Preoperative appraisal of urinary and bowel endometriosis

In this lecture, the preoperative assessment of endometriosis, especially bowel and bladder endometriosis, is discussed. The preoperative work-up facilitates the surgical management and defines any multidisciplinary approach, if needed. Physical exam, ultrasonography, Magnetic Resonance Imaging (MRI) and other tests are outlined. Evidence-based medicine conclusions are also cited for each method of evaluation.

Preoperative appraisal of urinary and bowel endometriosis

In this lecture, the preoperative assessment of endometriosis, especially bowel and bladder endometriosis, is discussed. The preoperative work-up facilitates the surgical management and defines any multidisciplinary approach, if needed. Physical exam, ultrasonography, Magnetic Resonance Imaging (MRI) and other tests are outlined. Evidence-based medicine conclusions are also cited for each method of evaluation.

Drawbacks of single port surgery and their solutions

Single Incision Laparoscopic Surgery (SILS) is feasible for a variety of adult and pediatric general surgical conditions, allowing for scarless abdominal operations. In this lecture, Dr. Todd Ponsky presents all the technical aspects of this approach demonstrating the types of trocars, systems and instruments with video demonstrations.

Drawbacks of single port surgery and their solutions

Single Incision Laparoscopic Surgery (SILS) is feasible for a variety of adult and pediatric general surgical conditions, allowing for scarless abdominal operations. In this lecture, Dr. Todd Ponsky presents all the technical aspects of this approach demonstrating the types of trocars, systems and instruments with video demonstrations.

Laparoscopic hepatectomy: surgical aspects

In this lecture, Prof. Didier Mutter presents the various aspects of the laparoscopic approach in liver surgery, presenting the indications, the surgical technique, video demonstrations in different pathologies. The laparoscopic approach is feasible, has selected indications with many benefits for the patients but is a very challenging procedure, which needs advanced technology too.

Laparoscopic hepatectomy: surgical aspects

In this lecture, Prof. Didier Mutter presents the various aspects of the laparoscopic approach in liver surgery, presenting the indications, the surgical technique, video demonstrations in different pathologies. The laparoscopic approach is feasible, has selected indications with many benefits for the patients but is a very challenging procedure, which needs advanced technology too.

Segmental colonic resection for cancer of the splenic flexure

The laparoscopic approach for the treatment of splenic flexure (SF) colon cancer is not standardized and is a challenging procedure. The aim of this video is to show the possible segmental and oncological resections of a tumor of the splenic flexure.

J Leroy, J Marescaux

Surgical intervention

Segmental colonic resection for cancer of the splenic flexure

The laparoscopic approach for the treatment of splenic flexure (SF) colon cancer is not standardized and is a challenging procedure. The aim of this video is to show the possible segmental and oncological resections of a tumor of the splenic flexure.

Laparoscopic left pancreatectomy with spleen preservation for a suspicion of IPMN

Laparoscopic distal pancreatectomy is suitable for benign and premalignant neoplasms located in the body and tail of the pancreas. Spleen preservation following distal pancreatectomy is known to be safe. There are two distinct approaches to preserve the spleen during the dissection of the distal pancreas. The classic design is to identify, isolate, and preserve the splenic artery and vein. Alternatively, the splenic artery and vein are ligated with the pancreas, and perfusion of the spleen is assured by the short gastric vessels. Both are accepted as appropriate techniques to address a mass in the tail of the pancreas. This video demonstrates a left pancreatic resection with spleen preservation and ligation of the splenic artery and vein.

B Dallemagne, S Perretta, L Soler, J Marescaux

Surgical intervention

Laparoscopic left pancreatectomy with spleen preservation for a suspicion of IPMN

Laparoscopic distal pancreatectomy is suitable for benign and premalignant neoplasms located in the body and tail of the pancreas. Spleen preservation following distal pancreatectomy is known to be safe. There are two distinct approaches to preserve the spleen during the dissection of the distal pancreas. The classic design is to identify, isolate, and preserve the splenic artery and vein. Alternatively, the splenic artery and vein are ligated with the pancreas, and perfusion of the spleen is assured by the short gastric vessels. Both are accepted as appropriate techniques to address a mass in the tail of the pancreas. This video demonstrates a left pancreatic resection with spleen preservation and ligation of the splenic artery and vein.

Single access transumbilical laparoscopic appendectomy and cholecystectomy with curved instruments

Single Incision Laparoscopic Surgery (SILS) has the potential advantages of reduced postoperative pain and reduced port-site complications. In this lecture, Dr. Giovanni Dapri presents new curved instruments for single access laparoscopic surgery and shows the feasibility of this approach for appendectomy and cholecystectomy in selected cases.

G Dapri

Single access transumbilical laparoscopic appendectomy and cholecystectomy with curved instruments

Single Incision Laparoscopic Surgery (SILS) has the potential advantages of reduced postoperative pain and reduced port-site complications. In this lecture, Dr. Giovanni Dapri presents new curved instruments for single access laparoscopic surgery and shows the feasibility of this approach for appendectomy and cholecystectomy in selected cases.

Incisional hernia: laparoscopic approach

Incisional hernia is a common complication of abdominal surgery and it is often a source of long-term morbidity. The surgical treatment includes many different techniques and until today the choice may be difficult, remaining a challenge for the general surgeon. In this lecture, Prof. Didier Mutter presents the current options for the laparoscopic approach and shows video demonstrations.

Incisional hernia: laparoscopic approach

Incisional hernia is a common complication of abdominal surgery and it is often a source of long-term morbidity. The surgical treatment includes many different techniques and until today the choice may be difficult, remaining a challenge for the general surgeon. In this lecture, Prof. Didier Mutter presents the current options for the laparoscopic approach and shows video demonstrations.

Laparoscopic Roux-en-Y gastric bypass (LRGBP) redo after laparoscopic sleeve gastrectomy in a morbidly obese woman

With more and more bariatric procedures being performed, it is predictable that more patients will suffer from complications necessitating re-do surgery. We show the case of a laparoscopic sleeve gastrectomy being transformed into a laparoscopic Roux-en-Y gastric bypass.

M Vix, J Marescaux

Surgical intervention

Laparoscopic Roux-en-Y gastric bypass (LRGBP) redo after laparoscopic sleeve gastrectomy in a morbidly obese woman

With more and more bariatric procedures being performed, it is predictable that more patients will suffer from complications necessitating re-do surgery. We show the case of a laparoscopic sleeve gastrectomy being transformed into a laparoscopic Roux-en-Y gastric bypass.